A Clinical Librarian Embedded in Medical Education: Patient-Centered Encounters for Preclinical Medical Students.

Adding patient encounters and simulation to the preclinical years of medical school is becoming increasingly popular. This article describes the creation of active learning opportunities by a clinical librarian that are aimed at training preclinical students through the use of simulated patient scenarios. Scenarios for second-year students walk them through the evidence-based resources needed in clinical years and beyond through a standardized patient encounter. Scenarios for first-year students involve role-play of cases where the patient and physician bring contrasting ideas to the outpatient interaction. All scenarios are carried out under the guidance of a clinician and librarian.

Neonatal ovarian torsion complicated by intestinal obstruction and perforation, and review of the literature.

We present a case of neonatal ovarian torsion complicated by bowel obstruction and perforation and review the literature regarding the incidence of bowel obstruction in neonatal ovarian cysts, the presentation, and treatment. A term neonate was prenatally diagnosed with a cystic abdominal mass palpable on physical examination. A postnatal abdominal x-ray showed paucity of gas in the left hemiabdomen with rightward displacement of bowel loops. Exploratory laparotomy on day 2 of life revealed a large cystic mass in the left lower quadrant consistent with a torsed left ovary, an omental band causing strangulation of the bowel mesentery, and a perforation of the distal ileum. Our literature search revealed 19 reported cases of neonatal ovarian cysts resulting in bowel obstruction. Infants may present with a palpable abdominal mass, respiratory distress, as well as signs and symptoms of intestinal obstruction. Two mechanisms exist for bowel obstruction: adhesions caused by a torsed necrotic ovary and mass effect of a large ovarian cyst, often measuring 9 to 10 cm in diameter. Options to treat ovarian cysts include antenatal or postnatal aspiration, laparoscopy, and laparotomy. Cysts less than 4 to 5 cm can be observed, whereas operative intervention is indicated in symptomatic cases and in persistent or enlarging ovarian cysts.

Multicenter trial of the clinical activities tool to document the comparability of clinical experiences in obstetrics-gynecology clerkships.

PURPOSE: To assess the implementation of the Clinical Activities Tool (CAT) for facilitating Liaison Committee on Medical Education-required documentation of the comparability of obstetrics-gynecology (ob/gyn) clinical experiences and midclerkship feedback at multiple sites during one academic year. METHOD: Ob/gyn clerkship students at six U.S. medical schools were given CATs to guide and document clinical experiences from June 2006 to June 2007. Students used a paper CAT at five institutions and an electronic version at one. CATs listed procedures, skills, and topics recommended by the Association of Professors of Gynecology and Obstetrics and included a midclerkship feedback section. Resident/faculty signatures documented completion of items for paper CATs. Electronic CAT item completion was self-documented by students. Students completed a questionnaire on CAT use. RESULTS: At the six schools, 876 medical students rotated on ob/gyn clerkships; 808 (92%) submitted CATs. Mean item completion rate was 72%. Five of six schools achieved >/=70% completion rates. Midclerkship feedback signature rates ranged from 0% to 97.8% with four of six schools reporting >/=65% feedback. Comparability of clinical experiences and midclerkship feedback was successfully documented across sites for each institution (number of sites: range = 1-9; median = 5). Questionnaires on CAT use were submitted by 231 students (26%). Students using paper CATs reported that doing so clarified course objectives (93%), provided clerkship guidance/structure (93%), and facilitated interaction with faculty/residents (76%/74%). Students rated the electronic CAT significantly less favorably. CONCLUSIONS: CAT implementation at multiple institutions for documentation of student clinical experience comparability and midclerkship feedback was successful. Students evaluated the paper CAT positively.

Retention of medical genetics knowledge and skills by medical students.

PURPOSE: To determine whether specific knowledge and skills medical students acquire after completing a Year 1 genetics course are retained at the end of Year 3. METHODS: A genetics case was developed for an observed structured clinical exam at the end of Year 3. The case involved a pregnant patient who underwent population screening for cystic fibrosis and is identified as a carrier of a common mutation. Student's performance in completing eight essential genetic tasks taught in Year 1 was assessed by their ability to apply these concepts in the Year 3 observed structured clinical exam. RESULTS: A total of 212 students were included in the study. Performance on the essential tasks revealed that students were better able to discuss inheritance pattern (73.1%). Students were less likely to calculate and discuss fetal risk (25%), discuss the option of prenatal diagnosis if the father is a carrier (25%), and ask about a family history of cystic fibrosis (36.8%). Only half (50%) explained the test result and implications to the patient. There was no correlation between individual student exam scores in Year 1 and the eight essential genetics tasks scores assessed in the observed structured clinical exam (r = 0.003, P < or = 0.67). CONCLUSION: Third year medical students do not retain medical genetics knowledge and skills learned in the first year of medical school. Medical schools need to integrate genetics curriculum through the continuum of the 4 years of medical school.

Maternal hypothyroidism in early and late gestation: effects on neonatal and obstetric outcome.

BACKGROUND: Maternal hypothyroidism may be associated with a variety of adverse neonatal and obstetric outcomes. Whether these outcomes are affected by maternal thyroid status at initial presentation or in late gestation specifically within a dedicated antenatal endocrine clinic remains unclear. The effects of thyroxine dose requirement during pregnancy and serum concentrations of TSH within such clinic settings are still not known. OBJECTIVES: We investigated these outcomes in patients with hypothyroidism during early and late gestation. TSH levels and thyroxine dose requirement during early and late gestation were also evaluated. METHODS: We performed a retrospective study of data from 167 pregnancies managed in the antenatal endocrine clinic. Analysis of outcomes was linked to TSH at first presentation and in the third trimester. Outcome variables included: rate of caesarean section, pre-eclampsia, neonatal unit admission, neonatal weight and gestational age. Controlled TSH was defined as mothers with TSH between 0.1 and 2 with normal free thyroid hormone levels. RESULTS: The caesarean section (CS) rates were higher in the study cohort (H) compared with the local (C) rate (H = 28.7%, C = 18%). The higher rate in our patient cohort was not due to a higher rate of emergency section nor to a lower threshold for performing elective caesarean section. The infant birthweight (IBW) from mothers with TSH > 5.5 (H1) and mothers with TSH between 0.1 and 5.5 at presentation (H2) was [median (range)] 3.38 (1.73-4.70) vs. 3.45 (1.36-4.76); P = ns. The prevalence of low-birthweight (LBW) infants (< 2.5 g) in groups H1 and H2 was 15% and 4.8%, respectively [odds ratio (OR) = 3.55, 95% confidence interval (95% CI) = 0.96-10.31]. IBW from mothers with TSH > 2 (H3) and mothers with controlled TSH in the third trimester (H4) were similar [3.38 (1.78-4.4) vs. 3.46 (1.36-4.76); P = ns]. The prevalence of LBW in groups H3 and H4 was 9% and 4.9%, respectively (OR = 1.95, 95% CI = 0.52-7.26). The median thyroxine dose (microg) increased significantly during pregnancy (first trimester: 100; second trimester: 125, P < 0.001; and third trimester: 150, P < 0.001) associated with appropriate suppression of TSH levels in the second and third trimesters. Rates of pre-eclampsia or admissions to neonatal units were negligible. CONCLUSION: Thyroxine dose requirement increases during pregnancy and thus close monitoring of thyroid function with appropriate adjustment of thyroxine dose to maintain a normal serum TSH level is necessary throughout gestation. Within a joint endocrine-obstetric clinic, maternal hypothyroidism at presentation and in the third trimester may increase the risk of low birthweight and the likelihood for caesarean section. The latter observation was not due to a higher rate of emergency caesarean section nor to a lower threshold for performing elective caesarean section. A larger study with adjustments made for the various confounders is required to confirm this observation.

Fatores associados com recidiva precoce do hipertireoidismo após tratamento com radioiodoterapia / Factors associated to early recurrence of hyperthyroidism following 131I therapy

OBJETIVOS: Avaliar os fatores associados com persistência ou recorrência do hipertireoidismo após tratamento com131 I. METODOLOGIA: Análise retrospectiva de prontuários de todos os pacientes com hipertireoidismo tratados com dose fixa de 400MBq de131 I em um centro especializado (1992 a 1997). Dos 104 pacientes tratados nesse período, seis tinham bócio multinodular e um adenoma tóxico; 96 estavam usando tionamidas que foram descontinuadas 7 dias antes da administraçäo do iodo. RESULTADOS: Progressäo precoce para hipotireoidismo ocorreu em mediana de 88 dias (22-214) em 60 pacientes (57,7 por cento). Persistência ou recorrência do hipertireoidismo ocorreu em 13 pacientes (12,5 por cento) e foram relacionadas positivamente com a idade (p<0,007), embora näo relacionadas com o diagnóstico. Houve maior prevalência de doença persistente nos pacientes tratados com propiltiouracil previamente ao radioiodo do que naqueles tratados com carbimazol (35 por cento vs. 8 por cento; p<0,006). CONCLUSÕES: O efeito bloqueador das tionamidas na captaçäo do radioiodo parece ser mais prolongado em idosos. O efeito radioprotetor do propiltiouracil parece ser mais duradouro que o do carbimazol.